LEAF Summer Camp Registration

YOUR SPOT IS NOT RESERVED UNTIL YOU COMPLETE THE FORM!

Please complete the registration form below. You can also download the form and return it via email to Education@theLEAF.org

June 12-16: Celebrating Diversity through Music/Art

June 20-23: Celebrating Black History in America **No camp Mon, June 19 in honor of Juneteenth

July 3-7: OFF

July 10-14: Hip Hop

July 24-28: A LEAF International Experience

July 31-Aug 4: OFF

Aug 7-11: Songwriting & Recording

Aug 14-18: West African Drumming

Aug 21-25: Songs for Peace

Name of Child

Address

City, State, Zip

Child's Date of Birth

Child's Gender/Pronouns

Child's Age

Child's School

Child's Grade as of Sept 2023

Camp Week Attending

T-Shirt Size

Parent/Guardian Name

Name on Credit/Debit Card used for Summer Camp purchase

Parent/Guardian Phone

Parent/Guardian Alternate Phone

Work Phone

Parent/Guardian Email

Employer

Hours

Can we email you?

Can we Text you?

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Alternate Phone

Work Phone

Parent/Guardian Email

Employer

Hours

Can we email you?

Can we Text you?

Name of Child's doctor

Doctor's Address

Doctor's Phone

Name of Child's Dentist

Dentist Address

Dentist Phone

Hospital Preference

Medical/Dental/Emergency Authorization

I hereby give permission to LEAF Global Arts to secure emergency medical, dental, and/or emergency surgical treatment, and to provide emergency transportation for the above named minor child while in care. Non-emergency medical treatment or elective surgery is not included in this authorization

Please list any allergies, dietary restictions, or health concerns we should be aware of for your child.

Additional Emergency Contact Name

Additional Emergency Contact Phone

Additional Emergency Contact Relationship

Additional Emergency Contact Name

Additional Emergency Contact Phone

Additional Emergency Contact Relationship

Additional Emergency Contact Name

Additional Emergency Contact Phone

Additional Emergency Contact Relationship

Additional Pick Up Person Name

Additional Pick Up Person Phone

Additional Pick Up Person Relationship

Additional Pick Up Person Name

Additional Pick Up Person Phone

Additional Pick Up Person Relationship

Additional Pick Up Person Name

Additional Pick Up Person Phone

Additional Pick Up Person Relationship

Participation Acceptance

I hereby give permission to LEAF Global Arts for my child to do each of the following: ● Participate in a walking trip or to be transported in a vehicle for a field trip. ● Participate in developmentally appropriate, supervised activities outside of fenced playground / play area. ● I certify that I have read, understand, and accept the following representation, stipulations and hereby waive for myself, my personal representative, heirs and next of kin, and on behalf of my child: ALL CLAIMS, WHICH I MIGHT HAVE AGAINST LEAF, ANY OTHER PROVIDERS OF FACILITIES AND ANY OF THEM IN COMBINATION, and their officers, directors, agents, employees and contractors, for injury, accident, illness, property damage, death or other occurrence arising in any manner whatsoever out of my participation in activities sponsored by LEAF Global Arts. FURTHERMORE, I agree to indemnify, save and hold harmless LEAF global Arts from any and all loss, costs, damages, expenses, and attorney’s fees arising out of my participation, or the participation of persons who accompany me, in LEAF Summer Camp related activities.

Media Release

I grant permission to LEAF Global Arts and its legal representatives the irrevocable and unrestricted right to use, publish and broadcast my and my child (listed above) photograph(s), likeness and voice for trade, advertising, and any other purpose and in any manner and medium; and to alter the same without restriction. I hereby release LEAF Global Arts from all claims and liability relating to said photograph(s), likeness and voice.